Senior Manger, Clinical Excellence & Performance Improvement

Encompass Health • Birmingham, AL

6h • Remote

About The Position

Encompass Health is the leader in inpatient rehabilitation industry, you’ll feel the Encompass Health difference as soon as you join. We collaborate and provide high-quality, compassionate, individualized care for our patients, allowing us time to get to know them and help them achieve their goals during their rehabilitation journey.
Position Purpose
The Senior Manager of Clinical Excellence & Performance Excellence is a strategic leader responsible for ensuring continuous compliance with CMS Conditions of Participation (CoPs) and The Joint Commission (TJC) standards across all hospitals in the system. This role leads a comprehensive accreditation and compliance readiness program, assisting the National Director of Quality and the Regional Directors of Quality to guide hospital Directors of Quality & Risk (DQRs) through a structured preparation process prior to scheduled surveys and beyond survey preparation, ensure continued readiness, and implement sustainability of operational standards and processes. The Senior Manager also drives organizational excellence by building Lean Six Sigma capability, serve as Just Culture Champion, and developing a resilient, high-performing quality workforce.

Requirements

• Bachelor’s degree in Nursing, Healthcare Administration, or related field required; Master’s degree preferred
• Minimum of 7 years of experience in hospital regulatory compliance, accreditation readiness, or quality improvement.
• Demonstrated expertise in CMS Conditions of Participation and Joint Commission standards.
• Strong leadership, facilitation, and coaching skills.

Nice To Haves

• Lean Six Sigma Green Belt certification preferred.

Responsibilities

• Accreditation Readiness Program Oversight
• Develop and implement a standardized readiness framework for hospitals preparing for accreditation surveys.
• Provide strategic direction and operational support to DQRs throughout the readiness cycle.
• Maintain central repository of standardized tools and readiness resources.
• Ensure consistent use of standardized tools, tracer templates, and compliance checklists
• Monitor hospital progress and escalate readiness risk in close coordination with regional leadership team.
• Serve as a consistent resource for interpreting accreditation and CMS
• Conditions of Participation standards, addressing findings, and reducing repeat citations.
• Stay current on CMS and Joint Commission updates and translate changes into actionable guidance.
• Support cross-functional initiatives related to regulatory compliance, patient safety, and performance improvement.
• Collaborate with hospital leadership to align readiness and improvement efforts with strategic goals.
• Track and distribute The Joint Commission findings, as well as, internal mock survey findings to hospitals, regional, and home office staff.
• Assist in the tracking of state, CMS, QIO, QIN, and CMS Medicare Advantage complaints, investigations, and on-site surveys.
• Lean Six Sigma Education and Coaching
• Design and deliver Lean Six Sigma Course for DQRs on an ongoing basis.
• Guide participants through hands-on improvement projects aligned with hospital priorities.
• Workforce Development & Retention
• Coordinate with regional leadership to assist in the Developing DQR Program ensuring candidates are identified and successfully complete the program.
• Track data surrounding the program regarding applicants, completion rates, and successful placements.

Benefits

• Affordable medical, dental and vision plans for full-time and part-time employees and their families.
• Generous paid time off that accrues over time.
• Tuition reimbursement and continuing education opportunities.
• Company-matching 401(k) and employee stock purchase plans.
• Flexible spending and health savings accounts.
• A community of people who love what they do. Yes, we see that as a benefit.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior